osteomyelitis NCP | Pain | Inflammation


Nursing Diagnosis Acute pain related to inflammation and edema as manifested by guarding behaviour, restlessness, pain scale of 7/10 and verbalization of “ang sakit tlaga ng hita ko” Nursing Goal SHORT TERM: After 2-4 hours of providing appropriate nursing interventions, the patient will experience decreased perception of pain as manifested by decreased restlessness, patient will be more relaxed, decreased pain scale will be assessed and patient will verbalize decreased perception of pain. LONG TERM: After 6-8 days of providing appropriate nursing interventions, the patient’s inflammation and edema will be decreased. Nursing Interventions
1. Elevate the legs.

RATIONALE: To reduce swelling in the extremity affected.
2. Handle extremity with great care and gentleness.

RATIONALE: The wound itself is sometimes very painful and must be handled carefully and slowly.
3. Immobilize the affected area with a splint.

RATIONALE: To reduce pain and muscle spasms.

5. 9. Provide quiet and calm environment RATIONALE: To reduce stimulus thus promoting relaxation. Discuss with significant others ways in which they can assist client and to reduce precipitating factors that may cause/aggreviate pain. Encourage patient perform focused breathing. indoor games). Encourage adequate rest and sleep periods RATIONALE: To prevent fatigue. 8. 6. 10. RATIONALE: This is helpful to distract patient from the pain. Administer analgesics as prescribed. 7.4.g. Teach patient good body mechanics RATIONALE: To minimize pain in daily activities. watching TV. RATIONALE: To provide fast relief of pain and/or decrease intensity of pain. RATIONALE: This is a relaxation exercise which can alleviate the pain. Encourage diversional activities (e. . RATIONALE: To gain SO’s cooperation in care of the patient. listening to music.

RATIONALE: Level of activity/exercise depends on progression/resolution on inflammatory process. RATIONALE: To avoid pressure ulcers. Instruct use of siderails and overhead trapeze for position changes/transfers. RATIONALE: Increases blood flow to muscles and bone to improve muscle tone. 3. inability to move purposefully within the physical environment. . maintain joint mobility. 4. Nursing Interventions 1. RATIONALE: For safety and ease of movement. the patient will have an improved adaption to condition and will experience ease in physical mobility. Assist client reposition self on a regular schedule as indicated by individual situation. limited ROM.’’ Nursing Goal After 2-3 days of providing appropriate nursing interventions. Nursing Diagnosis Impaired physical mobility related to pain and use of immobilization devices as manifested by with reluctance to attempt movement.2. 2. and verbalization of ‘’nahihirapan ako sa paggalaw-galaw. imposed restrictions. decreased muscle strength/control. Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. Assess degree of immobility produced by pain.

Cyanosis suggests venous impairment. 3. RATIONALE: Maximizes joint function. . RATIONALE: Return of color should be rapid (3-5 secs. Nursing Goal After 2-3 days of providing appropriate nursing interventions. 3. Nursing Diagnosis Risk for peripheral neurovascular dysfunction related to interruption of blood flow secondary to disease condition. 4. standing. current situation of client. and walking. Assess general condition of and contributing factors to patient. RATIONALE: Decreased/absent pulse may reflect vascular injury and necessitates immediate medical evaluation of circulatory status. Assess capillary return. the patient will have a diminished risk to acquire peripheral neurovascular dysfunction.5. White. Evaluate presence/quality of peripheral pulse distal to injury via palpation. RATIONALE:Promotes venous drainage/decreases edema. maintains mobility.). Maintain elevation of inflamed extremity unless contraindicated by confirmed presence of compartmental syndrome. skin color. RATIONALE: Provide basis for understanding general. cool skin indicates arterial impairment. 2. Nursing Interventions 1. and warmth distal to inflammation. Encourage patient to maintain upright and erect posture when sitting.

and increased pain. e..5. especially in the lower extremities. Encourage patient to routinely exercise digits/joints distal to inflammation. . decreased skin temperature. 6. pallor. Investigate sudden signs of limb ischemia.g. RATIONALE: Enhances circulation and reduces pooling of blood. RATIONALE: Osteomyelitis may cause damage to adjacent arteries. with resulting loss of distal blood flow.

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